Pediatrics

Vaginitis

OVERVIEW: What every practitioner needs to know

Symptoms suggestive of vaginitis (vaginal discharge, vaginal itching or burning, change in vaginal odor) are a common reason adolescent and young adult women seek care; while less common, vaginitis also occurs among prepubertal girls. A careful history combined with an external genital examination and microscopic examination of vaginal fluid will usually establish the diagnosis; however, in some cases a complete pelvic examination and more extensive laboratory testing will be necessary.

Are you sure your patient has vaginitis? What are the typical findings for this disease?

Chemical irritants (ask about douching, use of deodorants), contact dermatitis/allergies (material in underpants, chemicals in some sanitary pads, soaps or bubblebaths, etc; latex allergy (if partner using latex condoms) or sensitivity to spermicides (nonoxynol-9), either as condom lubricated with spermicide or as stand-alone product

Sexual activity (new onset or change in activity, including new partner within 30-60 days). BV is associated with sexual activity, including non-penetrative digito-genital contact and oral sex; however, it is not considered a sexually transmitted infection. Women who are not sexually active can get BV. Having a female sex partner increases the risk for BV.

What laboratory studies should you request to help confirm the diagnosis? How should you interpret the results?

Mid-vaginal pH is an important diagnostic criterion. Normal pH is <4.5. pH >=5.0 likely indicates infection. Avoid obtaining pH from near or at the cervical os. Candidiasis usually not associated with pH >=4.5

Presence of trichomonads (motile or stationary) diagnostic for trichomoniasis. However, wet prep is only 50 to 65% sensitive, even when performed under ideal conditions by an experienced microscopist. Culture is more sensitive than wet prep but less sensitive than DNA-based (not yet FDA approved) and FDA approved point of care tests (unamplified RNA, rapid antigen). Any woman diagnosed with trichomoniasis should be tested for C. trachomatis and N. gonorrhoeae infection. One suggested protocol for diagnosis of trichomoniasis in a population where the prevalence of infection is significant is to perform a wet prep first; if negative, perform a rapid antigen test. Culture has comparable sensitivity to rapid antigen tests, but results are available in days rather than minutes. KOH prep – presence of hyphae or buds suggests candidiasis. Hyphae and/or buds may also be seen on vaginal wet prep.

Large numbers of white blood cells not typically seen with VVC or bacterial vaginosis. Their presence suggests trichomoniasis or cervicitis/upper genital tract infection.

Women with cervicitis (mucopurulent discharge from cervical os and/or easily induced bleeding at the cervical os) should be tested for C. trachomatis and N. gonorrhoeae and, if clinically indicated, for herpes and T. vaginalis

Would imaging studies be helpful? If so, which ones?

Imaging studies are not indicated

If you are able to confirm that the patient has vaginitis, what treatment should be initiated?

Women being treated for bacterial vaginosis should avoid intercourse or use condoms during treatment (Table I). Women with trichomoniasis should avoid intercourse during treatment and until their sex partner(s) have been treated and are symptom-free (Table I).

Table I.

Condition

Medication

Dose

Bacterial vaginosis

Recommended

Metronidazole*

500 mg PO BID for 7 days OR

Metronidazole gel 0.75%

1 full applicator (5 g) once daily for 5 days OR

Clindamycin cream 2%**

1 full applicator (5 g) intravaginally at bedtime for 7 days

Alternatives

Tinidazole*

2 g orally once daily for 2 days OR

Tinidazole*

1 g orally once daily for 5 days OR

Clindamycin

300 mg orally BID for 7 days OR

Clindamycin ovules

100 mg ovule intravaginally once at bedtime for 3 days

Trichomoniasis

Recommended

Metronidazole*

2 g orally in a single dose OR

Tinidazole*

2 g orally in a single dose

Alternative

Metronidazole*

500 mg BID for 7 days

*Patients should be instructed to avoid alcohol during treatment with metronidazole or tinidazole and for up to 24 hours after metronidazole and 72 hours after tinidazole therapy is completed.

**Clindamycin cream is oil-based and may weaken condoms or diaphragms for up to 5 days after use.

Several treatment options are available for women with vulvovaginal candidiasis (Table II).

What are the adverse effects associated with each treatment option?

Metronidazole or tinidazole (oral): avoid use of alcohol during and for 24 hours after treatment with metronidazole and for 72 hours after tinidazole

Clindamycin cream: oil base may weaken latex condoms and diaphragms for up to 5 days

Topical therapy for candidiasis causes local burning in 5%-10% of patients

What are the possible outcomes of vaginitis?

Bacterial vaginosis: treatment is effective (80%-85%), but recurrence is common (30% by 3 months; up to 80% by one year).

Because re-infection following treatment of trichomoniasis is common (in one study 17% were re-infected within 3 months, and in another study 30% at one year), rescreening at 3 months can be considered.

A small percentage of women (<5%) will have four or more episodes of VVC in one year (recurrent vulvovaginal candidiasis or RVVC).

What causes this disease and how frequent is it?

Approximately 75% of women experience at least one episode of VVC; 40%-45% will have two or more. Adolescence is a typical time for a first episode. By age 25, half of all college students will have had one or more episodes of candidiasis. Risk factors include pregnancy, luteal phase of the menstrual cycle, nulliparity, recent use of broad spectrum antibiotics, use of spermicides, and age 15-19.

Prevalence of trichomonas infection is approximately 10%-20% (especially prevalent in women aged 16-35) but the prevalence varies widely depending on the population sampled. Risk factors include change in sex partners, intercourse twice weekly or more, 3 or more partners in the past month, and the presence of other sexually transmitted infections.

The prevalence of bacterial vaginosis also varies widely (10%-50%). The etiology of bacterial vaginosis is unknown, but a change in vaginal ecology (predominance of lactobacillus) results in an overgrowth of Gardnerella vaginalis and anaerobes (Prevotella spp, Peptostreptococci, Mobiluncus spp). Risk factors for bacterial vaginosis include more than one sex partner, change of partner in the last 30 days, having a female sexual partner, and douching.

How do these pathogens/genes/exposures cause the disease?

What complications might you expect from the disease or treatment of the disease?

Bacterial vaginosis is associated with adverse pregnancy outcomes such as preterm birth and low birthweight infants. It is also associated with increased risk for pelvic inflammatory disease, post-abortion infection and HIV infection.

Are additional laboratory studies available; even some that are not widely available?

How can vaginitis be prevented?

Condoms can decrease the risk for trichomoniasis and bacterial vaginosis.

Avoid douching, use of scented products (soaps, sanitary pads) or other feminine “hygiene” products. Limit use of broad spectrum antibiotics or steroids whenever possible. Avoid wearing nylon or tight undergarments or wearing exercise clothing for long periods of time (anything that traps moisture against the perineum).

A Cochrane review concluded that there is insufficient evidence to recommend for or against the use of probiotics in the treatment of bacterial vaginosis or prevention of recurrence.

Marrazzo, JM, Martin, DH. “Management of women with cercvicitis”. Clin Infect Dis. vol. 44. 2007. pp. S102-10. (Although now 5 years old, a good review of what we know and don't know about cervicitis.)

Ongoing controversies regarding etiology, diagnosis, treatment

The etiology of BV is uncertain; it is not a true vaginitis because there is no evidence of inflammation when present. BV is associated with sexual activity but is not considered a sexually transmitted infection. It is not clear whether asymptomatic women with BV who are not pregnant or about to undergo genital tract instrumentation should be treated.

Previous research suggested that recurrences of trichomoniasis were due to reinfection; however, more recent studies (using more sensitive detection methods) suggest that in some women, treatment temporarily suppresses levels of organisms to a level that cannot be detected, but over time symptoms recur. (See reference #3 by Huppert above for more detail).

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